Step 1 of 4 - Personal Information 25% Step-1 Personal InformationFirst Name* Last Name* Date of Birth MM slash DD slash YYYY Other Name (If Applicable) Social Security Number CURRENT ADDRESSStreet* Apart Number City* State* Zip* Time Spent at This Address* PREVIOUS ADDRESSStreet Apart Number City State Zip Time Spent at This Address Home Phone*Cell PhoneOther PhoneEmail* If hired, can you provide proof of legal right to work in the US?* Yes No Position Applying for Administrative RN Regional DON LPN HHA PCA Homemaker PT/OT/RT MSW Clerical Other Referral SourceWalk-InGovernment Employment AgencyEmployeeRelativeSchoolPersonOther Step-2 Education HistoryHigh School Name and Address Did You Graduate? Yes No Course of Major Diploma or Degree Year Completed College Name and Address Did You Graduate? Yes No Course of Major Diploma or Degree Year Completed Graduate School Name and Address Did You Graduate? Yes No Course of Major Diploma or Degree Year Completed Business School Name and Address Did You Graduate Yes No Course Major Diploma or Degree Year Completed Training Program Name and Address Did You Graduate? Yes No Course Major Diploma or Degree Year Completed Step-3 Previous Work HistoryPrevious Employer Name Address PhoneStart Date End Date Job Title Supervisor's Name Salary Reason for Leaving Previous Employer Name Address PhoneStart Date End Date Job Title Supervisor's Name Salary Reason for Leaving Previous Employer Name Address PhoneStart Date End Date Job Title Supervisor's Name Salary Reason for Leaving Additional ReferencesName Address / Phone Number Relationship Name Address / Phone Number Relationship Name Address / Phone Number Relationship Step-4 AvailabilityHHA Hours Available (Check all that apply) 4 Hours (AM) 4 Hours (PM) 8 Hours 12 Hours (AM) 12 Hours (PM) Live-in Applying For : Full Time Part Time I Prefer ; Days Evenings I am flexible Enter Your Available Hours BelowMonday Tuesday Wednesday Thursday Friday Saturday Sunday Will you work overtime (if required) Yes No If no, please explainPosition Desired Salary Desired Date you can start MM slash DD slash YYYY Have you ever been bonded? Yes No If yes, by whom? Have you ever been convicted of a crime? Yes No If yes, please explain Professional LicencesProfession License No: Exp. Date: Verification Date / Person Have you ever been sanctioned by Medicare / Medicaid? Yes No School / Training Program: Para-Professional Education: HHA PCA Verification Date / Person List any foreign language(s) other than English and your skill level.List any additional information you would like us to consider.I certify that the information given by me is true and correct and without any omission. I understand and agree that any false statement or intentional omission on this application or any subsequently furnished from constitutes cause for discharge at any time during my employment by At Home Personal Care Services, LLC. (AHPCS) I authorize AHPCS investigate all statements made in this application. I further authorize AHPCS to make any investigation of my credit, criminal and driving records in connection with this application and anytime thereafter in connection with my employment. I authorize the references listed in this application, to provide AHPCS will all information concerning my previous employment and any other pertinent information about me that they may have. I understand that all information obtained during pre-employment screening is held by AHPCS in confidence and will not be released to a third party unless AHPCS is required by law or is specifically authorized to do so by me. I further understand that if I am hired, I will not have an employment contract and that my employment and compensation can be changed or terminated with or without notice or cause at any time by AHPCS. AHPCS is an equal opportunity employer. We do not discriminate because of age, race, creed, color, sexual orientation, disability, citizenship status, national origin, marital status, veterans status or the presence of a non-job related medical condition or handicap or any other legally protected status.NameThis field is for validation purposes and should be left unchanged.
